Transitions of Care in Diabetes-Patient Flow From Diagnosis

Patient Flow From Diagnosis

Pdf Summary

The document outlines a systematic approach for integrating a newly diagnosed diabetes patient into a personalized treatment plan based on guidelines from the American Diabetes Association's Standards of Medical Care in Diabetes—2024. The process involves several key visits and assessments to ensure a smooth transition and ongoing management.

1. <strong>First Visit</strong>: Occurs at the primary care office where a nurse, alongside a designated diabetes champion, assesses the patient's understanding of their diabetes type, medication, and blood glucose management. The potential for a personal continuous glucose monitor (CGM) is introduced, pending insurance coverage.

2. <strong>Second Visit</strong>: Involves a meeting with the primary care physician (PCP) who tailors a care plan using accurate glucose data and reviews any applicable CGM reports. The patient is also referred for Diabetes Self-Management Education and Support (DSMES) services, needed at five critical times: diagnosis, annually, when treatment goals aren't met, with complicating factors, and during life or care transitions.

3. <strong>Third Visit</strong>: The patient consults a Certified Diabetes Care and Education Specialist (CDCES) for a thorough assessment focusing on technological integration to enhance safety, ease, and glycemic control. The visit addresses diabetes distress, co-existing health issues, and emphasizes equity in care.

4. <strong>Fourth Visit</strong>: The patient follows up with the PCP, who makes necessary care plan adjustments based on prior evaluations and outlines the frequency of future check-ups. The PCP also emphasizes the importance of regular maintenance and preventive care, including annual eye exams and biannual dental visits.

This structured approach aims to improve patient outcomes, care experience, and reduce costs, ensuring ongoing support and management for individuals with newly diagnosed diabetes.

Keywords

diabetes management

personalized treatment

American Diabetes Association

continuous glucose monitor

Diabetes Self-Management Education

Certified Diabetes Care Specialist

glycemic control

care plan adjustments

preventive care

patient outcomes